Date Posted: Saturday, July 06, 2024

 

Modifiers in medical coding serve to indicate specific circumstances that alter the usual definition of a service or procedure, often in response to payment policy requirements established by various entities. Detailed definitions of these modifiers can be found in Appendix A of the Current Procedural Terminology (CPT®) 2023 code set.

 

Modifier 25 Overview

 

Modifier 25, "Significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other Qualified Healthcare Professional (QHP) on the same day of the procedure or other service," is crucial for indicating distinct services performed on the same day. While unchanged in the CPT 2023 code set, confusion persists regarding its correct application.

 

Appropriate Use

 

Modifier 25 is applied when an E/M service provided by a physician or QHP on the same date as another procedure or service is significant and separately identifiable. This E/M service must exceed the usual preoperative and postoperative care associated with the primary procedure, substantiated by documentation in the patient's record.

 

It's important to note that Modifier 25 does not require different diagnoses for the E/M service and the procedure or service performed on the same day. However, it should not be used if the E/M service results in a decision to perform surgery; in such cases, Modifier 57, "Decision for surgery," is more appropriate. For distinct, independent non-E/M services, consider using Modifier 59, "Distinct procedural service."

 

Considerations for Correct Reporting

 

Key considerations when using Modifier 25 include:

• Specific Application to E/M Services: Modifier 25 should only be appended to E/M service codes, as outlined in various sections of the CPT code set, such as Hemodialysis, Allergy and Clinical Immunology, and Drug Infusions.

• Awareness of Preoperative and Postoperative Services: When reporting an E/M service alongside another procedure, ensure that the E/M service includes work beyond the typical preoperative and postoperative services included in the surgical package.

• Multiple E/M Services: If multiple E/M services are performed on the same date, each applicable E/M code should be accompanied by Modifier 25. Detailed guidelines for these scenarios are provided in respective subsections, such as Preventive Medicine Services and Newborn Care Services.

 

Examples of Proper Use

 

Here are a few examples illustrating the correct application of Modifier 25:

• E/M Service with Preventive Medicine Service: During a preventive medicine visit, if an additional significant problem requires a separate E/M service, append Modifier 25 to the office or other outpatient visit E/M code.
  
  
• E/M Service with Non-E/M Service (e.g., OB/Gyn Visit): When performing an E/M service alongside a non-E/M service, like a bladder catheterization, use Modifier 25 to denote the separate E/M service.
  
  
• E/M Service with Emergency Department Visit: In an emergency setting where significant E/M services are provided alongside wound repair, Modifier 25 indicates the distinct E/M service.
  
  
• E/M Service with Diagnostic Procedure (e.g., Laryngoscopy): When a diagnostic procedure like a laryngoscopy is performed along with an E/M service, Modifier 25 should be appended to the E/M code to denote the separately identifiable E/M service.

 

Conclusion

 

Proper use of Modifier 25 ensures accurate coding and billing, reflecting the distinct nature of E/M services provided on the same day as other procedures or services. Healthcare providers are advised to adhere closely to CPT coding guidelines and document services comprehensively to support modifier use.

 

Source: AMA